- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.94 / $218.58 / $229.32
| Professional | | $168.94 | $218.58 | $229.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.67 / $738.37 / $874.14
| Facility | | $546.67 | $738.37 | $874.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.72 / $203.20 / $339.84
| Professional | | $172.72 | $203.20 | $339.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.63 / $292.48 / $292.48
| Facility | | $223.63 | $292.48 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.51 / $292.48 / $292.48
| Professional | | $213.51 | $292.48 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.34 / $242.07 / $321.50
| Professional | | $174.34 | $242.07 | $321.50 |